Help Wanted: Healthcare Struggles with Revenue Cycle Management

The healthcare industry has become exponentially more complex since the beginning of the decade, particularly in how hospitals, health systems, and other health facilities derive revenue from payers. Once upon a time, we lived in a fee-for-service world where a health provider would send in a bill and the payer would simply pay it. Today, regulatory changes associated with quality of care result in a much more complex revenue cycle, particularly the mid-revenue cycle — that period between the patient’s first access to care and payment of the bill.

Health information management provides the yardstick by which healthcare organizations measure value-based medicine for quality of care, reimbursements, and regulatory compliance. Healthcare organizations must act strategically to stop the loss of revenue due to documentation gaps and errors in medical coding and billing that lead to payer denials, inaccurate reimbursements, and even penalties for overbilling. Organizations must comply with a host of complex compliance requirements that entail accurate coding, along with developing effective information management for case management and utilization review.

Coding complexities. Since 2015, all HIPAA-covered entities have upgraded to ICD-10. The question is, how good is the quality of documentation, coding, and information management infrastructure at these healthcare organizations? Are they keeping up with the constant regulatory and technology changes, along with all the new code sets? Is the quality of documentation and coding accurate enough to capture the revenue they’re owed, maintain accurate cancer and trauma registries, and support case management, utilization review, and clinical documentation improvement? How good are their healthcare coding education programs for nurses, physicians, and other clinicians?

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Many healthcare organizations may be unsure of the answers. They have put coding and health information management resources in place to respond to ICD-10 and other documentation requirements, but the quality of those resources may be uncertain. Each hospital and healthcare facility has multiple quality and efficiency initiatives underway, but most resources and attention are focused on patient-care programs. Needs in all other areas, including health information management, likely take a back seat. And even if they are ready to address health information management issues, many organizations can’t find enough quality coders and information managers, of which there are shortages in healthcare just like nurses and physicians. Leadership is more likely to be expert in clinical or financial issues rather than in health information management; they may not have the experience to address quality issues.

Consolidation in the healthcare industry gives rise to a new array of challenges, often related to the centralization of coding and health information management at the newly consolidated and much larger organization. The centralized department may have to absorb coders and managers who have worked on completely different platforms and structures. They may come from organizations with widely differing quality and practice standards, or the consolidated companies may provide new types of patient services that are unfamiliar to other coders and managers in the centralized department. The new leadership of consolidated coding and information management may need a lot of help.

Expert partners. Coding and information management challenges differ from hospital to hospital, clinic to clinic, and health system to health system. Mandates and requirements may be the same, but responses, usually developed organically at each facility or organization, can be very different. If healthcare leaders and managers begin to question the quality and accuracy of their coding and information management, they may require an expert partner who can customize solutions ranging from bringing in a few expert coders backed up by quality assurance or a complete turnkey operation.

When the healthcare industry was ramping up for ICD-10, most healthcare organizations assumed that coding and information management had to be internal capabilities. With compliance deadlines behind us now, all organization have some infrastructure in place. However, with a shortage of skilled coders and managers, many find that quality, not just productivity, is their problem today.

Quality is the problem when revenue is lost due or billing is improper due to undercoding or overcoding errors. The answer is quality assurance through education, pre-bill audits, continual assessment training of coders and managers, platform upgrades, retrospective reviews, record analyzing through artificial intelligence and machine learning, and other services and procedures.

If a healthcare facility or system does not have this capacity, or the resources to scale up its coding and health information management to solve current and future challenges, it may need to seek an expert partner for help. The loss of revenue, threat of penalties, demands for regulatory compliance, and technology needs of value-based care are too critical to leave at risk.


Linda Murphy

Linda Murphy
Linda Murphy is senior vice president, MedPartners, AMN Healthcare.

Linda Murphy

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